Non-Specific Neck Pain - the Case for Specific Treatment
- 1 Introduction
- 2 What do we know about neck pain?
- 3 The Psychological Domain
- 4 The Biological Domain
- 5 The Social Domain
- 6 Reducing the burden of non-specific neck pain with preventative exercise
- 7 References
Neck pain and low back pain were the leading cause of global disability in 2015 in most countries. In most instances, neck pain is considered to be non-specific as there is no known patho-anatomical cause.
However, according to Professor Jull, there are inherent risks in using the “non-specific” label for neck pain. These risks include:
- Physiotherapists failing to appreciate variations within and between the domains of the biopsychosocial framework for individual patients
- Physiotherapists prescribing generic treatment across all domains of the biopsychosocial framework rather than considering each patient’s unique presentation
What do we know about neck pain?
Most people get better from an episode of neck pain. Moreover, education and advice are usually sufficient for people who have neck pain. However, 50-75% of people who experience neck pain will experience another episode within 1-5 years or they will have continuing neck pain.
Jull, therefore, poses the question of whether reducing pain during a specific episode of neck pain should be our main aim. She suggests that focusing only on pain relief fails to consider the burden generated by repeat acute events over the years. These include:
- Loss of quality of life
- Loss of productivity
- Cost of treatments
- Cost of harm (ie side effects of drug treatments)
Like any condition, it is important to consider the biopsychosocial model when assessing and treating patients with neck pain.
The Psychological Domain
However, there is no strong evidence that psychological interventions for acute or chronic neck pain or whiplash result in clinically relevant changes to neck pain and disability.
Why aren't psychological interventions helping?
Jull suggests that these interventions are failing in part because they are not being applied specifically - ie not everyone will respond to the same intervention and, in some instances, applying a psychological intervention may have no effect.
While recent research has shown a link between neck pain and psychological symptoms, these symptoms are more significant in some patients than others. A study by Park and Kim found that 28% of patients with chronic neck pain attending a pain clinic were depressed. Thus 72% had no symptoms of depression al all.
Moreover, a study by Nazari et al. found that psychological responses often decrease as pain decreases. In fact, many psychological symptoms or emotions are a natural response to injury and pain, so as Jull notes we should not pathologise normal human reactions.
Thus, while it is important to recognise psychological features and try to incorporate psychological awareness into our treatment, it doesn’t mean that this should be our primary focus. However, it is essential to recognise the need to refer on to mental health practitioners if it is warranted.
The Biological Domain
Manual examination and therapy have been de-popularised in some quarters, but according to Jull, the scientific basis for this is poor. While there are many things that manual therapy cannot do (ie it has little effect on neuromuscular and sensorimotor function), it remains useful.
- Manual examination is vital in the diagnosis of neck pain. The Flexion Rotation Test, for instance, has face validity, as well as 90% sensitivity and 88% specificity to distinguish cervicogenic headache with C1-2 dysfunction.
- Similarly, a cluster of three tests has even shown to be sensitive (94%) and specific (84%) means of diagnosing cervical facet joint dysfunction. These tests are:
- the extension-rotation test
- manual spinal examination
- palpation for segmental tenderness
- Manual therapy is effective in reducing neck pain as a single modality or as part of a multimodal programme
However, like psychological interventions, manual assessment/therapy needs to be specific. A lack of skills in these areas, risk non-specific diagnosis and treatment for neck pain.
Neuromuscular and sensorimotor function
Neck pain causes many changes in neuromuscular and sensorimotor function, which do not automatically resolve as the pain diminishes. This has been demonstrated in patients with whiplash, cervicogenic headache and in patients with cervical vertigo.
Exercise is essential if these impairments are to be addressed. However, the research to date has not provided a clear picture of which exercises are most effective. Quite different exercise programmes have all been shown to reduce headache and neck pain. However, if the primary outcome focuses on restoring muscle function in order to prevent further episodes of neck pain, then the choice of exercise is important.
Impaired muscle function in neck pain
Patients with neck pain have reduced strength, decreased endurance and greater fatiguability. Changes in motor control are also evident. For instance:
- There is a tendency for greater dysfunction in the deep cervical extensors.
- Christensen et al. found that neck pain causes some reorganisation in axio-scapular muscle activity - for instance, with arm elevation tasks, there is delayed activity of serratus anterior and reduced duration of muscle activation of serratus anterior during arm elevation and lowering.
- Falla et al. found that there are signification variations in muscle activation in the deep neck flexors during the craniocervical flexion test in neck pain patients versus healthy participants.
These changes are significant when considering the prevention of recurrent neck pain. When looking at the physiological effects of different modes of exercise (including motor relearning training, endurance/strength training and mobility training), motor control/motor relearning exercises improved muscle action in the cranio-cervical flexion test (CCFT). Strength and mobility training had no effect. Motor learning improved the timing of the deep cervical flexors, but it had no effect on strength and endurance. All interventions improved range of motion.
Reducing recurrence of neck pain
It is important to know the specific types of exercises needed for different muscle impairments and different sensorimotor impairments. However, reducing recurrence has not been the main objective in previous randomised control trials (RCTs). To truly look at reducing recurrence rates, we need RCTs that test the effect of neuromuscular and sensorimotor retraining that is specific to the impairment.
The Social Domain
Computer use has been linked with an increasing prevalence of neck pain. More than 6 hours of computer use per day increases a person’s risk of developing neck pain. Similarly, when using a tablet, the mechanical demand on the extensor muscles increases 3-5 times when compared to a neutral posture. However, neck pain is not specific to any particular profession. Time in the workplace alone seems to increase the tendency to develop moderate to severe neck pain in some young adults.
Reducing the burden of non-specific neck pain with preventative exercise
To be adopted, exercises need to be:
- safe, short, simple and effective
- incorporated into daily activities
- suitable for all ages.
Jull recommends primary prevention should look at activating and training endurance capacity of postural muscles:
- Bring spine to a neutral position to take the load off the joints
- Reciprocal relaxation of levator scapulae (NB this occurs when the scapular depressors are contracted)
- To be completed 2 x per hour - correct posture and hold for 10 seconds
- Mobilising exercise - archery exercise
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